CALIFORNIA - Pacificare Health Systems

PART A
6
Getting Started:
Your Primary Care Physician
Director in consultation with the Member, the
Non-Participating Provider and, as applicable, the
newly enrolled Member’s assigned Participating
Provider.
Continuity of Care also applies to those new PacifiCare
Members who are receiving Mental Health care services
from a Non-Participating Mental Health Provider at
the time their coverage becomes effective. Members
eligible for continuity of mental health care services
may continue to receive mental health services
from a Non-Participating Provider for a reasonable
period of time to safely transition care to a Mental
Health Participating Provider. Please refer to “Medical
Benefits” and “Exclusions and Limitations” in Section
5. Your Medical Benefits of the PacifiCare Combined
Evidence of Coverage and Disclosure Form, and the
Schedule of Benefits for supplemental mental health
care coverage information, if any. For a description
of coverage of mental health care services for the
diagnosis and treatment of Severe Mental Illness (SMI)
and Serious Emotional Disturbances of a Child (SED),
please refer to the behavioral health supplement to this
Combined Evidence of Coverage and Disclosure Form.
A Non-Participating Mental Health Provider means a
psychiatrist, licensed psychologist, licensed marriage
and family therapist or licensed clinical social worker
who has not entered into a written agreement with
the network of Providers from whom the Member is
entitled to receive Covered Services.
PacifiCare
Attention: Continuity of Care Department
Mail Stop: CY 44-164
P.O. Box 6006
Cypress, CA 90630-9938
Fax: 1-888-361-0514
All Continuity of Care requests will be reviewed on a
case-by-case basis. Reasonable consideration will be
given to the severity of the newly enrolled Member’s
condition and the potential clinical effect of a change
in Provider regarding the Member’s treatment and
outcome of the condition under treatment.
PacifiCare’s Health Services department will complete
a clinical review of your Continuity of Care request
for the completion of Covered Services with a Non-
Participating Provider and the decision will be made
and communicated in a timely manner appropriate
to the nature of your medical condition. In most
instances, decisions for nonurgent requests will be
made within five (5) business days of PacifiCare’s
receipt of the completed form. You will be notified of
the decision by telephone and provided with a plan
for your continued care. Written notification of the
decision and plan of care will be sent to you, by United
States mail, within two (2) business days of making
the decision. If your request for continued care with a
Non-Participating Provider is denied, you may appeal
the decision. (To learn more about appealing a denial,
please refer to Section 9. Overseeing Your Health
Care.)
If you have any questions, would like a description
of PacifiCare’s continuity of care process, or want to
appeal a denial, please contact our Customer Service
department.
Please Note: It’s not enough to simply prefer receiving
treatment from a former Physician or other Non-
Participating Provider. You should not continue care
with a Non-Participating Provider without our formal
approval. If you do not receive Preauthorization
from PacifiCare or your Participating Medical Group,
payment for routine services performed by a Non-
Participating Provider will be your responsibility.
If You Are Pregnant
Every Member of PacifiCare needs a Primary Care
Physician, including your newborn. If you are
pregnant, we encourage you to plan ahead and pick a
Primary Care Physician for your baby. Newborns remain
enrolled with the mother’s Participating Medical Group
from birth until discharge from the hospital. You may
enroll your newborn with a different Primary Care
Physician or Participating Medical Group following the
newborn’s discharge by calling PacifiCare’s Customer
Service department. If a Primary Care Physician isn’t
chosen for your child, the newborn will remain with
the mother’s Primary Care Physician or Participating
Medical Group. If you call the Customer Service
department by the 15th of the current month, your
newborn’s transfer will be effective on the first day
of the following month. If the request for transfer is
received after the 15th of the current month, your
newborn’s transfer will be effective the first day of the
second succeeding month. For example, if you call
PacifiCare on June 12th to request a new doctor for
your newborn, the transfer will be effective on July 1st.
If you call PacifiCare on June 16th, the transfer will be
effective August 1st.